The Iliac Crest Osteomuscular Flap for Bony Reconstruction: Beast or Beauty? A Reassessment of the Value and Donor Site Morbidity in the CAD/CAM Era.

BACKGROUND: The iliac crest bone flap (ICBF), based on the deep circumflex iliac artery, has a bad reputation regarding donor site morbidity. However, the ICBF has an ideal curvature and shape for occlusion-based hemimandibular reconstructions with rapid dental rehabilitation and for vertical class III maxillary reconstructions that require bony support and muscular bulk to fill cavities and to provide intraoral lining. Is this notorious donor site reputation still valid with modern flap procurement using computer aided design/computer aided manufacturing (CAD/CAM) and recipient-site closure techniques? METHODS: We performed a literature search of the public databases PubMed, Cochrane, Google Scholar, and Web of Science for papers using mesh keywords related to donor site morbidity of the ICBF. We report three illustrative case reports using our current protocols for oncologic bony resection and reconstruction, using in-house CAD/CAM and three-dimensional printing to procure a tight-fit ICBF and minimizing donor site morbidity. RESULTS: We found 191 articles in the PubMed database of which we considered 176 nonrelevant. Cochrane Library and Google Scholar database searches resulted in the inclusion of 11 additional papers. The second search resulted in 172 articles of which we used five after excluding nonrelevant papers. Accurate preoperative (CAD/CAM) planning, preservation of the anterior superior iliac spine (ASIS), and paying attention to thoroughly donor site closure make the ICBF a very valuable option for accurate maxillofacial reconstructions with very acceptable comorbidities. This corresponds with our clinical findings. CONCLUSION: Dogma never is a good teacher; it remains elementary that routine "knowledge" is (re)questioned. Donor site morbidity of the ICBF is comparable to other bone flaps. The shape and bone stock of the ICBF is ideal and often may be first choice. In combination with CAD/CAM planning, the ICBF is an excellent option for specific maxillofacial reconstructions.

Limiting the fascia incision length in a DIEP flap: Repercussion on abdominal wall morbidity.

BACKGROUND: The evolution from free muscle-sparing transverse rectus abdominis myocutaneous flap to deep inferior epigastric perforator (DIEP) flap leads to less donor-site morbidity. However, rectus fascia is usually incised longitudinally from perforator(s) to iliac vessels, often exceeding 15 cm when including longitudinal muscle spreading. By using a limited fascia incisional (LFI-) technique, we try to diminish abdominal wall functional decrease. METHODS: Twenty-seven patients who underwent unilateral breast reconstructions using free DIEP-flap with limited fascia incision between December 2014 and October 2017 were included in the study. Each patient received a periumbilical electromyogram (EMG) preoperatively, at 6 and 14 weeks postoperatively. They were compared with 27 patients having unilateral breast reconstructions using classic free DIEP-flap, performed at the same department between November 2009 and May 2011. RESULTS: In our LFI-technique, one vertical (4 cm) incision is made where the pedicle exits the muscle. A second, oblique (3 cm) incision is made more distally where the pedicle runs into the iliac vessels. After release, the pedicle is tunneled through the incisions, leaving all fascia, and therefore muscle, intact. In the LFI-group small neurogenic changes were noticed in only 26% and 11% of the patients at, respectively, 6 and 14 weeks postoperatively. By contrast, in the control group, postoperative neurogenic deviations remained in 37% of the patients at 14 weeks postoperatively; significant different compared to the LFI-group. CONCLUSION: This study shows the importance of preserving anterior rectus fascia. Nerve supply and abdominal rectus muscle function are less endangered using small segmental fascia incisions. We believe that our technique diminishes donor-site morbidity significantly and improves the postoperative recovery.